INTRODUCTION — Urinary incontinence, the involuntary leakage of urine, is often underdiagnosed and undertreated [1-3]. In one survey, only 60 percent of patients seeking care for leakage (at least once weekly) recalled receiving any treatment for their incontinence [4]. Additionally, nearly 50 percent of those who did receive treatment reported moderate to great frustration with ongoing incontinence.

This topic will discuss the treatment of urinary incontinence in nonpregnant women, focusing on the initial management of stress and stress predominant mixed urinary incontinence (MUI), overflow, and functional incontinence.

●The treatment of urgency urinary incontinence/overactive bladder (OAB) and urge predominant MUI is described separately. (See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment".)

●The evaluation of urinary incontinence, for both males and females, and incontinence related to pregnancy and delivery are discussed separately. (See "Urinary incontinence in men" and "Evaluation of females with urinary incontinence" and "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we recognize that not all genetic females identify as women, and we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

PRIOR TO INITIATING TREATMENT

Identify indications for referral — Indications for further evaluation or referral for treatment of urinary incontinence include the presence of associated abdominal/pelvic pain, gross or microscopic hematuria in the absence of urinary tract infection, culture-documented recurrent urinary tract infections, new neurologic symptoms, suspected urinary fistula or urethral diverticulum, chronic catheterization, difficulty passing a urinary catheter, pelvic organ prolapse beyond the hymen, history of pelvic reconstructive surgery or pelvic irradiation, or persistently elevated postvoid residual (after treatment of possible causes). (See "Evaluation of females with urinary incontinence", section on 'Specialist referral'.)

Assess incontinence type and severity — Determining the classification of urinary incontinence type (stress, urgency, mixed) can help direct treatment.

Treatment of urinary incontinence should proceed in a stepwise fashion with emphasis on improving quality of life. Risks and side effects of therapy should be carefully balanced with benefits and aligned with patient goals and expectations. While most women with incontinence will have an improvement in symptoms with therapy, some do not achieve full continence. Expectations about the effect of treatment should be discussed with the patient when initiating therapy. (See "Evaluation of females with urinary incontinence", section on 'Evaluation'.)

A baseline assessment of symptom severity with a voiding diary (form 1) provides insight into fluid intake and output that can be used to counsel women about appropriate voiding frequency and bladder volumes. A voiding diary can also give an objective assessment of severity and may be helpful in assessing impact of treatment.

Tools are available to assess the impact of incontinence on a patient’s quality of life, which can aid in baseline assessment, focus treatment goals, and evaluate treatment efficacy. Tools that patients can complete include the International Consultation on Incontinence Questionnaire, The King's Health Questionnaire, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and OAB Questionnaire. The Patient Global Impression of Improvement (PGII) and the Patient Global Impression of Severity (PGIS) (table 1) are simple questionnaires that can document treatment progress in a reliable way [5,6].

Pads and protective garments — Although protective garments do not address the underlying cause of urinary leakage, many women with incontinence use pads and protective garments. Pads designed for incontinence are preferred over menstrual pads, as menstrual pads have poor absorbency for urine. While protective items are available at minimal to no cost in many European countries, in the United States these items are costly and rarely covered by insurance, except Medicaid.

Chronic exposure to urine-soaked pads can result in contact dermatitis and skin breakdown. Minimizing leakage and ensuring regular changes when leakage occurs are important, especially when used in a nursing home setting. (See "Prevention of pressure-induced skin and soft tissue injury", section on 'Minimize excess temperature and moisture'.)

Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and United States-based urinary incontinence patient advocacy groups, such as The Simon Foundation and the National Association for Continence. Women should be counseled that leakage is not a normal part of aging and that goals of treatment include minimizing or eliminating the need for the use of pads as a self-management strategy.

INITIAL TREATMENT — Initial treatments for most types of incontinence (stress, urgency, or mixed) include lifestyle modifications and pelvic floor muscle exercise, along with bladder training in women with urgency incontinence and in some women with stress incontinence [7-13]. We typically treat with these conservative therapies for six weeks before considering subsequent therapies. It is also reasonable to treat with conservative therapies for up to six months, particularly in obese women who are likely to experience improved bladder control following weight loss.

Modifying contributory factors — Before starting any treatment for urinary incontinence, contributory factors such as medical conditions and medications should be addressed, particularly in older patients (table 2) [14]. (See "Evaluation of females with urinary incontinence", section on 'Other contributing factors/conditions'.)

Lifestyle modification — Weight loss in obese women has many benefits, including improvement of urinary incontinence symptoms. Although commonly recommended and generally low risk, other lifestyle modifications that focus on dietary changes, fluid restriction, and caffeine reduction have been less studied [15]. At least one study has reported that support group teaching of these approaches improved urinary and bowel incontinence symptoms in women [16].

●Weight loss – Obesity is a known risk factor for urinary incontinence, and weight loss in obese women appears to improve symptoms of urinary incontinence [15,17-22]. Studies show greater benefits for stress incontinence than urgency incontinence. For example, one randomized trial of 338 overweight and obese women (mean body mass index [BMI] 36 kg/m²) found that weekly incontinence episodes decreased in women assigned to an intensive six-month weight loss program compared with a control group (47 versus 28 percent) [17]. Mean weight loss was 7.8 kg in the intervention group and 1.5 kg in the control group. While the difference in the groups was driven by a decrease in episodes of stress incontinence but not urgency incontinence, more women in the intervention group had a ≥70 percent reduction in the frequency of all incontinence episodes. (See "Obesity in adults: Overview of management".)

●Dietary changes – Some beverages may exacerbate symptoms of urinary incontinence [23]. We ask patients to reduce consumption of alcoholic, caffeinated, and carbonated beverages [24,25]. Women who are drinking excess amounts of liquids (>64 ounces of liquids) should normalize their fluid intake, unless there is a medical reason why they need to consume more liquids. We do not restrict fluid consumption below this level as this can lead to dehydration. Women are advised to consume liquids (mostly water) in small amounts of throughout the day, rather than drinking large volumes at one time. We also ask women who complain of nocturia to decrease or eliminate liquid consumed after dinner (or within several hours before bedtime). (See "Nocturia: Clinical presentation, evaluation, and management in adults", section on 'Initial measures'.)

●Constipation – Constipation can exacerbate urinary incontinence and increase the risks of urinary retention [26]. Constipation should be treated as indicated. (See "Management of chronic constipation in adults".)

●Smoking cessation – Smoking has been associated with an increased risk for urinary incontinence [25,27]. Beyond the general health benefits of smoking cessation, no studies have evaluated whether smoking cessation decreases urinary incontinence. (See "Overview of smoking cessation management in adults".)

Pelvic floor muscle (Kegel) exercises — Consistent with guidelines from the American College of Physicians, we suggest pelvic floor muscle (Kegel) exercises for women with urinary incontinence, particularly stress urinary incontinence [28]. Pelvic muscle (Kegel) exercises strengthen the pelvic floor musculature to provide a backboard for the urethra to compress on and to reflexively inhibit detrusor contractions.

Initial instructions — These exercises can be effective for both stress and urgency incontinence [29] (see "Patient education: Pelvic floor muscle exercises (Beyond the Basics)"). The basic regimen consists of three sets of 8 to 12 contractions sustained for 8 to 10 seconds each, performed three times a day. Patients should try to do this every day and continue for at least 15 to 20 weeks [30].

A systematic review of randomized trials found that, compared with no treatment, women treated with pelvic muscle exercises were more likely to report improvement or cure of any urinary incontinence (67 versus 29 percent; relative risk [RR] 2.39; 95% CI 1.64-3.47) [29]. (See "Evaluation of females with urinary incontinence", section on 'Stress urinary incontinence' and "Evaluation of females with urinary incontinence", section on 'Urgency urinary incontinence'.)

Patients have better outcomes with regular exercise and proper technique. Adequacy of pelvic floor muscle contraction can be assessed during the pelvic examination. The examiner places one or two fingers within the vagina and asks the patient to contract her pelvic floor using the same muscles she would use to stop urine flow or bowel gas [31]. In women who are able to isolate their pelvic floor muscles to stop urine flow, verbal instruction on timing and frequency of exercise is usually sufficient. For those with difficulty identifying the proper muscles, supplemental modalities can help women to perform these exercises properly.

Supplemental modalities — For women who are able to isolate pelvic floor musculature, supplemental therapy may not be necessary. However, other patients may have difficulty because of poor muscle isolation, low motivation, or inability to properly contract the pelvic floor. For these patients, we use supplemental therapies such as supervised pelvic floor therapy, vaginal weighted cones, or biofeedback (based on patient preference, access, and availability), although systematic reviews have not identified any of these modalities as superior over others [32].

●Supervised pelvic floor therapy – Women who have difficulty performing the exercises or have no improvement with unsupervised exercise may benefit from referral to a pelvic floor physical therapist or continence nurse where available [33]. Pelvic muscle exercises are most effective with specific instruction by health professionals and regular performance by motivated patients. It is not clear how much health care supervision is optimal [32,34]. Both group and individual sessions appear to be helpful [35].

●Vaginal weighted cones – Pelvic muscle exercises can be supplemented by the use of weighted vaginal cones. These may be preferable for women who have insufficient time or resources to dedicate to supervised physical therapy or biofeedback. The woman inserts the cone in her vagina and uses pelvic muscle contractions to hold it in place during activity. A 2013 systematic review and meta-analysis of 23 small randomized trials found some evidence that cones have increased efficacy over no active treatment but inconclusive evidence that they provide increased efficacy over standard pelvic floor muscle exercises [36]. Vaginal weighted cones are available without a prescription and typically ordered online or from a medical supply store.

●Biofeedback – Biofeedback as a supplement to pelvic muscle exercises is particularly useful in women who are unable to properly isolate the pelvic floor or use accessory muscles during pelvic floor contractions. This modality involves placement of a vaginal pressure sensor within the vagina that measures pressure and provides an audible or visual feedback of strength of pelvic floor contraction. Augmented versions also use abdominal and perineal electromyography (EMG) recordings to demonstrate improper contraction of abdominal and gluteal muscles. In the United States, biofeedback is covered by Medicare for patients who fail an initial four-week trial of behavioral therapy. Biofeedback is often used in conjunction with supervised pelvic floor physical therapy.

•Biofeedback – A 2011 systematic review and meta-analysis of 17 randomized or quasi-randomized trials found that compared with women who received pelvic floor muscle exercises alone, those that also received biofeedback were more likely to report improvement or cure of urinary incontinence (RR 0.75, 95% CI 0.66-0.86) [37].

•With electrical stimulation – Biofeedback can also be done using electrical stimulation. The device is placed in the vagina or anus and provides a small electrical current that stimulates the pelvic floor muscles to contract, aiding the patient in identification and isolation of the proper muscles. A 2012 review of nine studies found that, compared with sham stimulation, intravaginal electrical stimulation improved continence rates for women with urgency, stress, or mixed incontinence [38].

•With electromyographic biofeedback – A trial of 600 females comparing pelvic floor muscle therapy with and without electromyographic biofeedback reported similar outcomes in International Consultation on Incontinence Questionnaire-urinary incontinence short form (ICIQ-UI SF, range 0 to 21, higher scores indicate greater severity) scores at 24 months [39]. The addition of electromyographic feedback does not appear to improve long-term outcomes.

●Mobile applications (apps) – While both free and paid apps exist to aid pelvic floor muscle training and address urinary incontinence in females, their efficacy has not been well studied. One study identified 139 mobile apps targeting female stress urinary incontinence; 20 met criteria for review [40]. Of the 20 apps, only one had been trialed and verified in the literature with reported efficacy [41]. Based on the Mobile App Rating Scale (MARS) tool (0 to 5 rating scale), the median MARS for the 20 apps was 3.6, with a range of 2.7 to 4.1 [40].

In clinical practice, we use the “just do it” approach. Whatever mode or regimen that will motivate women to perform proper pelvic floor muscle exercise is encouraged. Some may need the motivation of a timed or scheduled appointment with a specialist, while others simply need the encouragement and support to perform the exercise on their own. Recommendations and referrals should be tailored to the patient’s preference and needs.

Bladder training — Bladder training is most effective for women with urgency incontinence [38]. Some women who have stress incontinence only at higher bladder volumes may also benefit from the timed voiding component to keep bladder volumes below that where stress incontinence occurs. Bladder training and pelvic muscle exercises are often used in combination with dietary and lifestyle modifications (eg, fluid restriction to 1800 mL/day and avoidance of caffeinated beverages). While evidence supporting bladder training is generally weak, clinical experience supports the practice [42-44].

Bladder training starts with timed voiding. Patients should keep a voiding diary (form 1) to identify their shortest voiding interval. The shortest voiding interval is used when initiating bladder training. The patient is instructed to void by the clock at regular intervals while awake, using the shortest interval between voids identified on the voiding diary as the initial voiding interval. Urgency between voiding times is controlled with either distraction or mental relaxation techniques (eg, performing mental math, deep breathing) along with quick contractions of the pelvic floor muscles "quick flicks" to suppress urgency and bladder contraction [7]. When the patient can avoid leakage for one day using the initial urination interval, the time between scheduled voids is increased by 15 minutes. The intervals are gradually increased until the patient is voiding every three to four hours without urinary incontinence or frequent urgency.

A patient bladder training instruction sheet is shown (table 3).

Successful bladder training can take up to six weeks. Patients often need encouragement and reassurance to continue despite initial lack of response.

Patients should be encouraged to void regularly even when outside of the home.

Topical vaginal estrogen — We suggest a trial of vaginal estrogen therapy for peri- or postmenopausal women with either stress or urgency incontinence and vaginal atrophy due to genitourinary syndrome of menopause (GSM). GSM is associated with urinary frequency and dysuria and can contribute to incontinence. Available preparations include creams, rings, gelcaps, and tablets (table 4). We use topical estrogen cream 0.5 gm twice weekly (conjugated estrogen or estradiol), estradiol tablet 10 mcg twice weekly, or the estradiol ring every three months. It may take up to three months for patients to perceive treatment benefit and some patients may require higher doses. The product choice is determined by patient preference, insurance coverage, and ease of use. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment".)

We do not recommend systemic (oral) estrogen therapy for urinary incontinence. Evidence suggests that systemic hormone therapy may worsen urinary incontinence [38,45,46].

Systemic absorption is low with topical vaginal estrogen at the recommended initial dose, and major systemic risks appear low [47]. A study of women followed for a mean of seven years found no increases in cardiovascular or cancer-related risks in women using vaginal estrogens compared with non-users [47]. (See "Menopausal hormone therapy: Benefits and risks", section on 'Urinary incontinence' and "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Serum absorption'.)

A systematic review and meta-analysis of four randomized trials of postmenopausal women found that vaginal estrogen was associated with improved continence (RR 0.74; 95% CI 0.64-0.86) [45]. Three of the four trials were restricted to patients with stress incontinence, and statistical heterogeneity between trials limits confidence in the conclusion of the meta-analysis. A subsequent review suggests that vaginal estrogen may be useful as an adjunctive treatment for women with incontinence, although the quality of the evidence was poor to moderate [48].

The safety of vaginal estrogen in women with a history of breast cancer is discussed separately. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Patients with breast cancer'.)

STRESS INCONTINENCE TREATMENT — If initial treatments described above are not sufficient for patients with stress incontinence, external support devices may be an effective next step. Patients without adequate relief should be referred for additional treatment options.

Devices — Continence pessaries are the most common, traditional form of support devices and may be used for women with stress incontinence either as an adjunct or substitute for pelvic muscle exercises. Overall patient satisfaction rates are approximately 50 percent at one year [49]. These are generally fitted by a gynecologist or urologic continence specialist. An over-the-counter device called the Impressa is also available. (See "Vaginal pessaries: Indications, devices, and approach to selection".)

In unselected patients, the addition of devices to pelvic floor muscle exercises does not appear to improve outcomes over exercises alone [49,50]. However, we find devices can be useful for patients who have stress incontinence that occurs with specific activities or situations (eg, exercising or experiencing an upper respiratory infection with cough-related incontinence).

Other devices have been developed to be placed within the urethra or vagina to prevent urinary leakage. Their use is limited by high rates of urinary tract infections and lack of evidence regarding long-term safety and efficacy [51].

Pharmacotherapy — No pharmacologic therapies have been approved by the US Food and Drug Administration (FDA) for treatment of stress incontinence in women, although multiple medications have been evaluated [52].

●Duloxetine – Duloxetine is a serotonin-norepinephrine reuptake inhibitor that may be effective for incontinence. However, because of potential adverse effects, we do not routinely use duloxetine as treatment for stress incontinence. If patients require treatment for depression, it is reasonable to discuss the option of duloxetine as primary treatment for depression due to the potential benefit of decreasing incontinence.

Systematic reviews of duloxetine in stress urinary incontinence find that treatment is associated with improvements in quality of life, >50 percent reductions in incontinence episodes (relative risk [RR] 1.56; 95% CI 1.46-1.66), and global improvement (RR 1.24; 95% CI 1.14-1.36) but were unable to determine if outcomes were sustainable and noted that one in three patients reported adverse events [53,54].

●Other medications – Alpha-adrenergic agonists (eg, phenylpropanolamine), which stimulate urethral smooth muscle contraction, had been used previously for the treatment of stress incontinence. They are no longer recommended because they are only mildly efficacious compared with placebo and have a high rate of adverse effects [52,55].

There is insufficient evidence for the efficacy of imipramine in stress and mixed incontinence, and side effects are significant [55].

Surgery — Women without sufficient improvement with initial treatment and/or pessaries should be evaluated for surgical therapy. For women who desire more rapid and definitive treatment who are willing to accept risks of surgery, the midurethral sling (a minimally invasive surgical option) offers higher success rates than conservative therapy.

Surgery offers high cure rates for stress urinary incontinence. A trial of 460 women randomized to initial stress urinary incontinence management with physiotherapy (PT) versus a surgical midurethral sling procedure demonstrated crossover of 49 percent from conservative to surgical management and crossover of 11 percent from surgical to conservative management [56]. Self-reported improvement at one year was higher in women randomized to surgery than those who had PT (91 versus 64 percent), and a per protocol analysis of the surgical versus physical therapy groups showed an even greater magnitude of difference in demonstrated improvement with surgery (91 versus 32 percent) and in subjective cure rates (85 versus 16 percent) [56]. (See "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure", section on 'Women who decline or have persistent symptoms following conservative therapy'.)

Patients whose symptoms persist despite other therapies should have further surgical evaluation to discuss surgical options. (See "Stress urinary incontinence in women: Persistent/recurrent symptoms after surgical treatment", section on 'Urinary diversion'.)

Other specialty treatments — Transurethral radiofrequency collagen denaturation has been proposed as a minimally invasive device-based intervention to treat urinary incontinence. A systematic review and meta-analysis was able to find only one trial of 173 women that assessed this technology and concluded that it was not known if radiofrequency denaturation improved urinary incontinence symptoms because that outcome was not assessed [57]. In addition, the meta-analysis concluded that there was insufficient evidence to determine if the procedure improved disease-specific quality of life.

An intravesical balloon device for the treatment of stress urinary incontinence has shown efficacy and safety and has been associated with improved quality of life and satisfaction compared with a sham procedure [58]. Urethral bulking agent (UBA) therapy, also known as periurethral injection therapy, is rarely used as a primary treatment for stress urinary incontinence but remains an option for women with intrinsic sphincteric dysfunction in the setting of a fixed immobile urethra, with persistent/recurrent stress urinary incontinence after a standard anti-incontinence surgery, or for women who are unwilling or unable to tolerate a surgical procedure. (See "Stress urinary incontinence in women: Persistent/recurrent symptoms after surgical treatment", section on 'Periurethral injection therapy'.)

In a systematic review, electrical stimulation to improve pelvic floor function using non-implanted devices was found to be probably more effective than no treatment and maybe not much different than pelvic floor muscle training. There was not enough evidence to determine its relative effectiveness compared with drug therapy or surgery [59].

Electroacupuncture was evaluated in a multicenter randomized trial of 504 women in China with stress urinary incontinence. Compared with sham treatments, a course of 18 active treatments to the lumbosacral region over six weeks reduced urinary leakage by a mean of 10 grams from a baseline of 18 grams. During treatment, the number of incontinence episodes improved from a baseline of eight episodes to one episode per 72 hour-interval, with improvement maintained at two episodes per 72 hours approximately six months after the completion of treatment [60]. The availability of this therapy may limit this option; these results require confirmation before its general use can be widely recommended.

Pulsed magnetic stimulation was studied in an industry-sponsored, single site randomized trial of 120 patients [61]. Treatments occurred twice weekly for two or four months. A favorable response to treatment (measured using a standardized questionnaire) at two months was more common in patient receiving active compared with sham treatment (75 versus 22 percent). Investigators reported sustained improvement at 14 months was observed in more than 70 percent of patients who had received active treatment. There are no data comparing it with pelvic floor muscle exercises alone. Availability and insurance coverage may limit this option; these results require confirmation before its general use can be widely recommended.

There is insufficient evidence to support the use of vaginal laser (CO₂ or erbium) for the treatment of urinary incontinence in the setting of genitourinary syndrome of menopause [62].

URGENCY INCONTINENCE/OVERACTIVE BLADDER — We generally begin treatment of urgency, urgency-predominant mixed urinary incontinence (MUI), or overactive bladder (OAB) with the same conservative measures that are used for other types of incontinence in women, and we offer medications if initial treatment with incontinence is ineffective [13]. Some women, however, prefer to initiate pharmacologic therapy sooner and may do so without extensive evaluation or invasive testing if symptoms are clear and predominantly urgency-related. Treatment of urgency incontinence/OAB is discussed in detail separately. (See "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment".)

MIXED INCONTINENCE TREATMENT — For women with mixed urinary incontinence (MUI), which has components of both stress and urgency incontinence, we start with lifestyle modifications, pelvic floor muscle exercises, and bladder training [63]. A systematic review of five randomized trials found that a combination of pelvic floor exercises and bladder training improved symptoms [38]. (See 'Initial treatment' above.)

If initial treatments above are not effective, women are then treated based on their predominant symptoms (stress or urgency). While there are few data evaluating antimuscarinics in patients with MUI, those with urgency-predominant symptoms are treated similarly to those with pure urgency incontinence [64]. (See 'Urgency incontinence/overactive bladder' above.)

If the above interventions do not adequately treat the patient’s symptoms, we offer surgical treatment, typically with a mid-urethral sling. Initial concerns that mid-urethral sling insertion could worsen the urgency component have not been supported by data [9,65-67].

●In a trial of 416 women with MUI randomly assigned to receive a mid-urethral sling either with or without behavioral/pelvic floor muscle therapy, both groups reported significant improvement in their symptoms, with the combined treatment group having a greater improvement that, while statistically significant, did not meet the prespecified difference for clinical importance [68]. The retropubic sling improved both stress and urgency urinary incontinence symptoms of MUI, with symptom improvement reported by more than 85 percent of patients overall, and symptom worsening reported by fewer than 5 percent.

●At the one-year planned follow-up of the study group, while nearly 30 percent of patients (112 of 379) had treatment failure using both subjective and objective criteria, only 15 percent (56 of 379) needed additional treatment, with two of these being for stress incontinence [69].

A detailed discussion of surgical management for mixed urinary incontinence is presented in detail separately. (See "Surgical management of stress urinary incontinence in women: Choosing a primary surgical procedure", section on 'Mixed incontinence'.)

OVERFLOW INCONTINENCE — Overflow incontinence can mimic stress incontinence, urgency incontinence or mixed urinary incontinence (MUI). Women with overflow incontinence also may present with a variety of symptoms including involuntary, intermittent, or continuous urinary leakage with no warning or sensation, dribbling, and incomplete bladder emptying. Treatment of urinary incontinence associated with impaired bladder emptying depends upon the etiology. (See "Evaluation of females with urinary incontinence", section on 'Overflow urinary incontinence'.)

●Bladder outlet obstruction – Women with bladder outlet obstruction from previous vaginal or urethral surgery should be referred to a specialist for further evaluation. Obstruction from a large cystocele or uterine prolapse can be treated with a pessary or surgically. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Approach to management' and "Vaginal pessaries: Indications, devices, and approach to selection".)

●Detrusor underactivity – Specific treatment for patients with detrusor underactivity is limited. Potentially reversible causes of impaired emptying should be addressed, for example by stopping medications that impair detrusor contractility and/or result in increased urethral tone (table 2) or by treating constipation.

●Chronic urinary retention – When there is chronic partial urinary retention (eg, from prior spinal cord injury), clean intermittent catheterization may be used alone or in conjunction with the above approaches (see "Chronic complications of spinal cord injury and disease", section on 'Bladder dysfunction' and "Placement and management of urinary bladder catheters in adults", section on 'Clean intermittent catheterization') Chronic transurethral catheterization is not an appropriate long-term management strategy, and these women should be referred for consideration for suprapubic catheterization or urinary diversion.

Sacral nerve stimulation may be beneficial for patients with idiopathic or neurogenic underactivity and Fowler’s syndrome. In the United States, it is approved for the treatment of nonobstructive urinary retention. Success rates in general are not as promising as for urgency urinary incontinence and overactive bladder (OAB), and there is a high rate of reintervention within five years due to device malfunction. However, due to the relatively low morbidity and ability to perform a trial phase before permanent implantation, it is generally used prior to more invasive and permanent solutions [70-72].

Clean intermittent catheterization may be used to manage overflow incontinence due to detrusor underactivity. (See "Placement and management of urinary bladder catheters in adults", section on 'Clean intermittent catheterization'.)

SPECIAL POPULATIONS — When considering treatment for urinary incontinence, special consideration needs to be given to pregnant women or those with cognitive impairment or neurologic disease.

Pregnant women — The management of pregnant women with urinary incontinence is discussed in detail elsewhere. (See "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Symptom management during pregnancy'.)

Cognitive impairment and functional incontinence — When managing incontinence in adults with cognitive impairment, it should not be assumed that the cognitive impairment is the only cause of incontinence. Other factors (eg, functional impairment, comorbid conditions, and medications) should also be investigated and treated. Goals of care and treatment preference discussions should include the needs and wishes of the caregivers who will oversee or implement treatment [73].

Nonpharmacologic approaches (eg, prompted voiding, scheduling toileting) are preferred in persons with dementia because these individuals are particularly vulnerable to adverse effects of antimuscarinic agents.

Pharmacotherapies, particularly anticholinergic medications, should be used with caution as women with cognitive impairment may experience more side effects, and beta adrenergic medications as first-line medication should be considered [74]. (See "Evaluation of females with urinary incontinence", section on 'Evaluation' and "Medical care in skilled nursing facilities (SNFs) in the United States", section on 'Urinary incontinence' and "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Adverse drug effects'.)

Neurologic disease — Adults with specific neurologic diseases (eg, multiple sclerosis, spinal cord injury, Parkinson disease) often have associated bladder or sphincter impairment resulting in complicated mixed stress, urgency and overflow incontinence.

The treatment of urinary incontinence in adults with neurologic disease is discussed separately. (See "Chronic complications of spinal cord injury and disease", section on 'Urinary complications'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary incontinence in adults" and "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Urinary incontinence in females (The Basics)" and "Patient education: Pelvic muscle (Kegel) exercises (The Basics)" and "Patient education: Neurogenic bladder in adults (The Basics)" and "Patient education: Surgery to treat stress urinary incontinence in women (The Basics)" and "Patient education: Treatments for urgency incontinence in women (The Basics)")

●Beyond the Basics topics (see "Patient education: Urinary incontinence in women (Beyond the Basics)" and "Patient education: Urinary incontinence treatments for women (Beyond the Basics)" and "Patient education: Pelvic floor muscle exercises (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Patients with concerning symptoms on presentation (eg, sudden onset of incontinence or associated abdominal/pelvic pain or hematuria in the absence of infection) should be evaluated and/or referred for evaluation of underlying systemic conditions. (See 'Identify indications for referral' above.)

●Determining the classification of urinary incontinence type (stress, urgency, mixed) can help direct treatment. Having a baseline assessment of symptoms (eg, voiding diary, quality of life measures) can facilitate assessment of treatment efficacy. (See "Evaluation of females with urinary incontinence", section on 'History'.)

●Before starting any treatment for urinary incontinence, contributory factors such as medical conditions and medications (table 2) should be addressed. (See 'Modifying contributory factors' above.)

●Initial treatment includes lifestyle modifications and pelvic floor muscle exercises for all patients with urinary incontinence (stress, urgency, or mixed), along with bladder training in women with urgency incontinence. (See 'Initial treatment' above.)

•We suggest that women be instructed to properly perform pelvic muscle (Kegel) exercises (Grade 2A). (See 'Pelvic floor muscle (Kegel) exercises' above.)

•Bladder training is most effective for women with urgency incontinence. Some women who have stress incontinence at higher bladder volumes may also benefit from the timed voiding component to keep bladder volumes below that where stress incontinence occurs. (See 'Bladder training' above and "Urgency urinary incontinence/overactive bladder (OAB) in females: Treatment", section on 'Our approach to treatment'.)

•We typically treat initially for six weeks before considering subsequent therapies. (See 'Initial treatment' above.)

●In peri- or postmenopausal women with vaginal atrophy and either stress or urgency incontinence, we suggest topical vaginal estrogen (table 4) (Grade 2C).

●For women with stress incontinence with incomplete efficacy with lifestyle modification and pelvic floor muscle training, pessaries are offered, particularly to patients who have incontinence with particular activities. Patients without adequate relief should be referred to consider other options. (See 'Initial treatment' above and 'Stress incontinence treatment' above.)

For women who desire more rapid and definitive treatment who are willing to accept risks of surgery, the midurethral sling (a minimally invasive surgical option) offers higher success rates than conservative therapy. (See 'Surgery' above.)

●Treatment of mixed urinary incontinence (MUI) should begin with lifestyle modification and pelvic floor muscle training. Subsequent therapy should be focused first on alleviation of symptoms causing most degree of bother. While surgical treatment of stress symptoms may improve urgency symptoms, surgery should not be considered as a primary treatment for refractory urge incontinence. (See 'Mixed incontinence treatment' above.)

●Treatment of overflow incontinence is specific to the etiology. (See 'Overflow incontinence' above.)

●When beginning initial treatment for urinary incontinence, special consideration needs to be given to women who are pregnant or who have cognitive impairment or other neurologic disease. (See 'Special populations' above and "Effect of pregnancy and childbirth on urinary incontinence and pelvic organ prolapse", section on 'Symptom management during pregnancy'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Catherine E DuBeau, MD, who contributed to an earlier version of this topic review.